ASCLS Today Volume 33, Number 7

Beth Warning, MS, MLS(ASCP)^CM, ASCLS Region IV Director

Congratulations! You may have just celebrated 40 years as a medical lab professional and are looking forward to retirement. You may be known as the coagulation guru, the “pee queen,” or the key operator for one of the analyzers. You remember running lithium testing on the flame photometer, adding caffeine to your bilirubin tubes, and performing RIA as a “new” technology. What does this mean?

It is vital that seasoned medical laboratory professionals share with our developing professionals the expertise that they maintain. Photo courtesy of Floyd Josephat.

It means you have a long history in the profession and have witnessed many changes. You have experiential knowledge beyond any textbook. But how you use this knowledge is the key. As a seasoned tech, it is vital to share with our developing professionals the expertise that you maintain. In business, it may be called succession planning–in the lab, it requires transfer of the knowledge, skills, and level of practice to our next generation of laboratorians.

Recently, ASCLS leaders participated in a book club, reading Starts with Why, by Simon Sinek. While this book may have related to having great leadership to inspire marketing or management, as a scientist, I bet many of us started with why years ago. Your parents may have shared that “why” was your favorite or often-used word as a child. As scientists, we are challenged to ask this question in research. As educators, we hope to stimulate our students to both ask and answer the same “why” question.

So back to sharing your knowledge—often knowledge is not shared, the answer to “why” is not provided, and people move on, keeping information to themselves without realizing the benefit of continued learning.

“If we share our knowledge, answer the how and why questions in the field, our profession will be all the stronger.”

Knowledge Hoarders
There are names for these individuals who keep information as if it’s their own property. One is the knowledge hoarder. They see their expertise, job tasks, and skills as a form of job security, or even a form of power. The hoarder takes on new roles, learns new things, then keeps that knowledge to him or herself as a form of job security.

Knowledge hoarders may be some of the most frustrating people to work with. They may share what needs to be completed but are limited in the how to perform a task and completely avoid the why something should be done. Their resistance to sharing knowledge may stem from their fear of losing their advantage in the workplace. We need to quench the fear of losing status to keep their expertise within the organization.

Control Freaks
The knowledge hoarder is closely related to the control freak. Sure, we may be labeled as such as a laboratory professional, but in terms of knowledge sharing, this is the individual who has to know all the information. Then they can tell everyone how to perform a test, the best way (their way) to perform the test, and point out the mistakes and errors when something doesn’t go as planned. You know this person—they are the ones who think they know everything and give their advice freely without you actively seeking it.

While this person may not be sharing his or her expertise, they have strong opinions that their way is the only way and should be uniform across the lab. Knowledge sharing in this instance may need to be a two-way street, where the old adage of “leave your ego at the door” would apply.

Introverts
Some lab professionals may claim that they are not comfortable in training new employees or students. They hide by identifying as introverts, therefore keeping things close, not sharing much information in terms of work or workplace skills. It’s not something they are comfortable with, yet the expertise they display is irreplaceable in the workplace. There is a bridge that needs to be built, a mentorship or fostering of a relationship so that both individuals are comfortable in knowledge exchange.

Organizational Politics
Finally, there is always the political angle that prevents knowledge sharing—organizational politics, of course. This is where a person feels they are not adequately trained to teach, mentor, or even, not compensated for the role. This is an unfortunate position to be in, as our developing professionals and new employees are eager to learn and want to maintain or raise the bar on practice standards within the organization.

So how does this tie in with succession planning? Every lab needs to have a plan to capture and transfer this important knowledge. Through mentoring, the talents and skills of our retiring staff will be preserved and imparted to the next generation before retirement, in a structured format. Other options include documentation of processes and procedures by creating detailed process maps or SOPs for specific one-of-a-kind tasks. Job shadowing or retraining is another possibility.

In the laboratory, we are constantly challenged to learn new things—the test menu may be increased or decreased, analyzers come and go, and methodology changes. Add to this our large number of lab professionals reaching retirement age, and their knowledge is irreplaceable. Today’s workforce is more transient, moving from opportunity to opportunity, but if we share our knowledge, answer the how and why questions in the field, our profession will be all the stronger. Let’s promote succession planning and knowledge transfer for continuity of quality.

Beth Warning is assistant professor in the medical laboratory science program at the University of Cincinnati-College of Allied Health Sciences.

Brandy Gunsolus, DCLS, MLS(ASCP)^CM

Medical laboratories are continuously faced with more obstacles. However, the theme is inherently the same: do more with less. I have seen laboratories pinch pennies in an effort to make budget when supplies, shipping costs, and labor costs continue to increase. Some of the more creative efforts include utilizing a sterilization service for instrument sample cups instead of paying full price for new ones, and two labs combining their orders to obtain discount pricing they would not be able to have alone.

While trying to reduce our laboratory spending, we naturally look at what is commonly perceived as easy targets: reduce overtime, lean processes, and reduce wastage. However, with current labor shortages, overtime is one of those things that will happen, and most labs have already leaned their processes and reduced their wastage. While we have traditionally focused on these items as being the only ones perceived to be within our control, there is an area that laboratories can target to obtain savings for both the patient and the laboratory: send-out testing.

Physicians often order esoteric send-out testing because a journal article mentions a test that they perceive may have benefit for their current patient.¹ They often do not understand when a test still has not had its clinical utility proven; in essence, does the result of the test actually affect patient management, which would then improve the patient outcome?² With the ease of online searches, they may also acquire a false understanding of the true usefulness of a test.³

“Beginning to review your specimen referral testing, and the appropriateness of the testing, is a great way to make significant dents in your laboratory expenses.”

Establish a Laboratory Test Formulary
So how do laboratories face these challenges? One option is to establish a facility laboratory test formulary. Much like the drug formularies of our pharmacy colleagues, a laboratory test formulary is a listing of testing that has been vetted and approved by the laboratory. Utilization of any test not included on the laboratory test formulary would require special laboratory medical director permission and justification from the ordering provider. Medical laboratory personnel can lay the initial groundwork for this list, but the laboratory medical director would need to provide formal approval.

While establishing a laboratory test formulary may seem like a massive undertaking, it is easiest when written as an exclusionary list. Here, all laboratory testing is considered to be formularyapproved testing except a listing of the tests that are not approved and, thus, excluded from the formulary. This exclusionary listing also provides the opportunity to list why the exclusion from the approved laboratory test formulary and cite evidence supporting the exclusion of the test.

Communicate Why a Test is Excluded
So now you have a test that is excluded from the laboratory test formulary and a physician tries to order the test. What do you do? These are best handled by succinctly telling the physician the test is no longer on the laboratory test formulary due to whatever the reason the test was excluded. This could be lack of adequate validation of the test, the test is available as research use only, clinical utility of the test has not been adequately proven, or the test is only offered by a non-CLIA certified laboratory, such as those overseas. In my experience most physicians are understanding of formularies and rarely question these types of messages. Should you have any that do, those questions should certainly be handed over to your laboratory’s DCLS or medical director to be addressed.

Beginning to review your specimen referral testing, and the appropriateness of the testing, is a great way to make significant dents in your laboratory expenses. You may find easy wins—such as duplicate genetic testing—that you should easily be able to make a policy to cancel or an electronic medical record solution to prevent the initial order. You are also likely to find many test orders that should never be ordered and be restricted by a laboratory test formulary. By eliminating this type of unnecessary testing, you will reduce your laboratory reference laboratory invoices and reduce patient costs by not having to cover deductibles or costs of noncovered testing. You will never know what the potential for savings are until you look.

References

1. Greenblatt MB, Nowak JA, Quade CC, et al. Impact of a prospective review program for reference laboratory testing requests. Am J Clin Pathol. 2015; 143:627–634.
2. Astion M. How to say no to sendouts–strategies for coping with tests that aren’t ready for clinical use. Clinical Laboratory News. 2019. 45(10).
3. Astion M. The Google factor: are the worried well making healthcare sick. Clinical Laboratory News. 2014. 40(1).

Brandy Gunsolus is doctor of clinical laboratory science at Augusta University Medical Center in Augusta, Georgia.

For more on this and similar topics, join the Laboratory Administration/Consultant/Quality/Accreditation/Industry Scientific Assembly.

Christal Lane, MS, MLS(ASCP)^CM

Maya Angelou reciting her poem, “On the Pulse of Morning,” at Bill Clinton’s presidential inauguration in 1993.

One of my favorite quotes is from Maya Angelou: “Do the best you can until you know better. Then when you know better, do better.”

I’ve had this quote posted on mirrors, in lockers, and in various binders and planners over the years. Aside from the fact that Maya Angelou is one of my many role models, this quote has been a staple in my day-to-day life as I have gone through various stages of life.

I was unpacking some of my boxes from my most recent move and found the notecard that had been taped to a mirror with this quote. I smiled fondly as I placed it in the basket of things to be put in my new locker at the hospital. I didn’t realize how important this would be as I started training to move into my new position as a full-time medical laboratory scientist in the microbiology lab I had worked in as a student.

When I started training on the various benches, I began to panic. There was a lot to learn and at some point, I would be trusted to do this all on my own. I pulled my brand-new-butalready-well-worn notebook close as I continued to write down every. little. detail. so that I wouldn’t miss anything for when that day arrived. I was already making elaborate plans on how to re-write this treasure trove of a book so that my eclectic collection of notes might actually make sense down the road when I was on my own.

“I don’t know everything today, nor will I know it tomorrow, but tomorrow, I will know a little more.”

Fear would wake me up each morning (or did it keep me up all night?) because I was terrified of making a mistake. I did not want to mess up. I did not want to cause a patient harm, or worse, cause their death. But as I got home from work on a particularly overwhelming day (where I did in fact make a mistake), I found this quote from Maya. This quote in no way excuses my mistakes—nor will it ever do so. But this quote supplied me hope. Hope that though I don’t know everything today, nor will I know it tomorrow, but tomorrow, I will know a little more.

Today, I will do the best I can. I will ask you a ton of questions, and it may be the same question I asked you before (whether that was last month, last week, or 30 minutes ago). I may write it down, then write it down again, oh, and it will be transferred to the new notebook, too. But I am here to learn from you, to take all the knowledge that you have spent years acquiring, so that one day I will be able to give that knowledge to another.

Another great Maya quote before I go, you ask? “I do my best because I am counting on you counting on me.” I wrote this out on the notecard underneath my first Maya quote. I circled “you” and drew out lines from the word to what that word represents. My Coworkers. Doctors. Patients. My family. A future student. Myself.

Maya also once said that fear and hope cannot occupy the same space. Tomorrow, I will wake up with hope and start a new day to learn a new thing. I invite you to do the same.

Christal Lane is a medical technologist at Methodist University in Memphis.

For more resources for new professionals, visit the Ascending Professionals Forum.

W. Jon Windsor, MLS(ASCP)^CM

Figure 1: A map of endemic areas (in yellow) for A. americanum

Imagine all of your absolute favorite foods. Now, what if every time you enjoyed one of those foods, several hours later you were plagued with vomiting, stomach cramps, dizziness, and other symptoms closely resembling anaphylactic shock.¹ This is the harsh reality of those unfortunate enough to consume meat of any kind after suffering a bite from the “Lone Star Tick” (Amblyomma americanum).

The lone star tick is notorious for biting humans and transmitting different pathogens known for causing diseases like tularemia, human echrlichiosis, heartland virus disease, and bourbon virus disease. However, a lesser-known condition a bite can leave behind is known as STARI (Southern tick-associated rash illness).²

What is STARI
A tick bite that leads to STARI results in a rash with a presentation similar to Lyme’s disease. Unfortunately, that rash is just the start. As the rash resolves, an allergy to galactose-a-1,3-galactose (a-gal) emerges.¹

Figure 2: The lone star tick has a characteristic white dot on its back

A-gal is a carbohydrate found in the meat of several animals, excluding primates. A-gal is also found in the digestive lining of A. americanum. When we consume meat, a-gal becomes a great source for essential amino acid production. When the human body is exposed to a-gal through a tick bite, our immune system overreacts and mounts an allergic response with IgE antibodies.³

Very little research exists that has explored why this might occur. One theory is that the combination of lone star tick digestive proteins and a-gal mimic the “allergen epitope” that IgE antibodies readily bind to, which then identify a-gal as the “intruder” and elicits an immune response.⁴ What makes this under-researched phenomenon worse is that these lone star ticks are endemic to the Southeastern United States (Figure 1) with some high-risk areas going as far north as Maine.

According to the CDC, the times you are at the greatest risk for being bitten by A. americanum are between early spring and late fall. The way you can recognize this tick is by a characteristic white dot on its back (Figure 2).²

STARI is the precursor for the allergic response to meat, otherwise known as alpha-gal syndrome. Alpha gal syndrome is clinically diagnosed through a serious of questions asked by an allergist that seeks to gather information around the amount of meat you ate and the length of time after you consumed meat before symptoms started. A clinical diagnosis can be confirmed by both a skin IgE allergy test or by a blood test that measures the amount of IgE your body created in response to eating meat. The only way to “treat” alpha-gal syndrome is to avoid meat altogether. If anaphylaxis is a concern, allergists will prescribe an epi-pen.¹

“[S]uch a ground-breaking discovery in the word of allergy medicine can only drive researchers forward in their pursuit to combat anaphylaxis and remove the burden allergens have on people across the world.”

Discovering the Link to the Lone Star Tick
The most compelling thing about alpha gal syndrome is the obscurity that surrounds an allergy to meat. An association between a-gal and the development of an allergy to meat was made through a rather unusual discovery. In 2008, an article was published that a small portion of individuals who were given the colorectal cancer drug “cetuximab” during a clinical trial were experiencing an allergic reaction. After further inquiry, the researchers were able to conclude that a-gal IgE antibodies already present within the subjects’ immune systems were inducing these allergic reactions to the treatment.

The subjects who were allergic to a-gal primarily resided in Tennessee, Arkansas, and North Carolina, which are all present within the lone star tick-endemic areas.⁵ Eventually, enough people with a-gal syndrome reported exposure to ticks. This drove researchers to look for a-gal in the digestive systems of ticks to establish a link. Just recently in 2018, a group of researchers were able to establish the presence of a-gal in the saliva and digestive tracts of lone star ticks.³

It’s exciting that we have identified how a meat allergy and alpha gal syndrome are linked to lone star tick bites. However, allergens and the allergic response are still poorly understood. Very few treatments exist that have successfully mitigated the allergic response. With that being said, such a groundbreaking discovery in the word of allergy medicine can only drive researchers forward in their pursuit to combat anaphylaxis and remove the burden allergens have on people across the world.

References

1. Meat Allergy Overview. American College of Allergy, Asthma, & Immunology Allergest. 2014.
2. Shadick N MN, Hoak D. Tickborne Diseases of the United States a Reference Manual for Healthcare Providers. CDC. 2018.
3. Chandrasekhar JL, Cox KM, Loo WM, Qiao H, Tung KS, Erickson LD. Cutaneous Exposure to Clinically Relevant Lone Star Ticks Promotes IgE Production and Hypersensitivity through CD4(+) T Cell- and MyD88-Dependent Pathways in Mice. J Immunol. 2019;203(4):813-824.
4. Platts-Mills TA, Woodfolk JA. Allergens and their role in the allergic immune response. Immunol Rev. 2011;242(1):51-68.
5. Chung CH, Mirakhur B, Chan E, et al. Cetuximab-induced anaphylaxis and IgE specific for galactose-alpha-1,3-galactose. N Engl J Med. 2008;358(11):1109-1117.

W. Jon Windsor is Foodborne Diseases Centers for Outbreak Response Enhancement (FoodCORE) aide at the Colorado Department of Public Health and Environment in Denver.